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Gastroenterology  (Expert Forum)
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ascites progression with complications
Answered by
Kevin Pho, MD - Internal Medicine
Kevin, M.D. Boston - MA
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MedHelp Member's Question

ascites progression with complications

by MelanieLu, May 01, 2003 12:00AM
Hi Dr.Kevin, I'm so happy to have found your site and read with interest at the details of liver disease,via questions-answers.



I'm a 57yr old female with cirrhosis/ascites, diagnosed 2yrs ago,ascites onset.2 biopsies postponed due to excess fluid,had paracentisis w/fluid drainage excessive f/5days. A CT w/contrast showed nodules, slight kidney calcif.'s in Dec'02,mildly shrunken liver. This was 1yr(sober) from ct#1 w/enlarged liver as expected.Meds,lo sodium pr day(500mg)weight loss, 90lbs,weigh 162,5'6" My doc says I'm one of his best patients, foll his directions,absolutely, now am on 1,000mg sod. a day, (what a treat!)relearned how to cook,just terrific! I attend AA,have a wonderful sponsor,abstinent since diagnosis(7/01)sooo sick then,hi bl press,really hi,now 110-70 pretty consistently.

I look great feel great,few side effects, have so many questions,my doc is wonderful,gentle,caring,but as I understand,hesitant to predict much,just that 'I'm not sick',be happy, celebrate life, which I certainly do, with gusto and gratitude. I have some side problems, manageable,am on 2aldact-50mg,2furos.40mg pr day,AST25,ALT28,Sod 128,only hi#'s are BUN'34,creat.1.3,due to meds,Dr says.Am at Doc/labs monthly, carefully,but am interested in helping myself in all ways,read net a lot,but see the prognosis/outcome f/ascites so low,for hi percentage(50%in 2yrs,79%3rd),it's so scary.Do labs fall suddenly to result in mortality of 2yrs-3yrs? Or slowly?



Do Any/some w/my advanced(70%pr Doc/apprx cirrhosis)condition live well beyond or am I being a pollyanna? There isn't a hepatologst w/in 175miles but feel I might go,if warranted? Second opinion.My ins.company wouldn't renew(foll'g cobra)due to this,I'm uninsurable,but maybe for state ins.at $750mo.a tough situation, so am not a candidate f/liver transplant at all, due to this? Any ideas on any 'extra careful' steps,I could take,to stem the progression,I would do.Doc sooo busy,I ask but he isnt the type to get detailed.I'd feel better w/truth,have a disabled son,a dear fella,(Rubella)so unsure of his future w/out me,or am I way ahead w/good labs,management Child P score 5-6,little enceph and meds/ascites ok. Will meds stop working and all this change,death is forecast for me now,at every turn,(even by my doc at the outset when I pressed),it's a thorn among roses in my life, can't stop the worry, unless some do go on,beyond this.? Odds available?



My sis is an RN (ret'd)she's worried,loving support from her, my husband,other sisters,2 other recovering.Our parents died young,Dad,cirrhosis,Mom in childbirth, early 30's,found out soo late about 'factors',so heredity isn't good here either.(bro died,suicide@41yrs had cirrhosis).I'm wanting to do something to plan,try,improve,get help f/future inevitability

but not sure how, where or with whom.Indianapolis closest w/any specialists,appreciate your input Dr.thanks so much for being there,(you can bill more/so many questions!)MelanieLu :)
Doctor's Answer

by Kevin Pho, MD, May 02, 2003 12:00AM
Hello - thanks for asking your question.



Congratulations on quitting drinking and I'm happy to see that you've turned your life around.



As you can understand, it is difficult to predict mortality.  You have mentioned the Child's system of cirrhosis classification, and I will outline it here.  This is based on studies and is done on a point system.  



Criteria:



1) Total Serum Bilirubin

Bilirubin <2 mg/dl: 1 point

Bilirubin 2-3 mg/dl: 2 points

Bilirubin >3 mg/dl: 3 points



2) Serum Albumin

Albumin >3.5 g/dl: 1 point

Albumin 2.8 to 3.5 g/dl: 2 point

Albumin <2.8 g/dl: 3 point



3) INR

INR <1.70: 1 point

INR 1.71 to 2.20: 2 point

INR >2.20: 3 point



4) Ascites

No Ascites: 1 point

Ascites controlled medically: 2 point

Ascites poorly controlled: 3 point



5) Encephalopathy

No Encephalopathy: 1 point

Encephalopathy controlled medically: 2 point

Encephalopathy poorly controlled: 3 point



Interpretation

Child Class A: 5 to 6 points

One to two year patient survival: 85-100%



Child Class B: 7 to 9 points

One to two year patient survival: 60-80%



Child Class C: 10 to 15 points

One to two year patient survival: 35-45%



You note a Child's score of 5-6, suggesting a 1-2 year survival of 85-100%.  



In terms of things you can do, here are some suggestions:

- abstain from drinking (which you are doing)

- get tested for Hepatitis and treat appropriately if positive

- get Hepatitis A and B vaccines if hepatitis tests are negative

- don't use medications known to harm the liver (Tylenol, herbal remedies etc.)

- consider yearly influenza vaccine and a pneumococcal vaccine



With documented cirrhosis, you may want to inquire about the possibility of a liver transplantation.  You are on a good medical regimen - if you can tolerate it, then you should continue.  Your labs (normal AST/ALT and low sodium) are typical for someone who has advanced but inactive cirrhosis.  



Followup with your personal physician is essential.



This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.



Thanks,

Kevin, M.D.

Member Comments (11)

by dixiedarlin, May 01, 2003 12:00AM
To: Melanielu
Hello and I wanted to say good luck to you.  You sound like a very brave soul and also determined to do the best you can in this life with your illness.  My comment/question to you is in relationship to your drinking amount and the development of cirrhosis.  I am not a heavy drinker but have consumed alcohol for about 25 years almost daily.  I usually only have 2-3 glasses of wine a day and sometimes less.  I have worried about liver problems.  I have never had an abnormal liver function test - although I haven't had one in 4 years - and then only for a check up as a part of a lab panal.  I do have occassional right sided pain about 1-2 inches below the rib cage - could be intestinal and does seem gas related.  I have read many articles about women and cirrhosis and most state that 5 drinks or more  a day over about 15 years could lead to a problem.  I rarely have more than 3 a day.  I don't feel I have a problem with alcohol - no withdrawal etc. but do enjoy it and am in a social situation where it is almost always included in all get togethers etc.  I may consume 2-3 but it is usually over a period of 4 - 5 hours.  I have none of the classic signs of alcoholism - trouble with DUI's or work or personal life - no problems now or ever.  I just wanted some info from someone who knows what is the true amount to cause problems.  I do hope the best for you and your situation.  I appreciate any advice or input you have about your past alcohol consumption......thanks DD

by dixiedarlin, May 01, 2003 12:00AM
To: Melanielu
I forgot to mention I am 46 years old and I also wondered what were your first signs you had a liver problem.....   thanks again for your input....DD

by MelanieLu, May 02, 2003 12:00AM
Hi dixiedarlin, so nice of you to write, I guess we're all so different, I had many periods of long sobriety, no one more surprised than me, at what occurred. I had the typical 'morning afters', many times, as I've heard around the tables at AA for yrs., symptoms as I now know, but ignored, thinking, I can stop and I have, but I'll get past this. We know how that ended.



Not sure you understand the complication of ascites, as I've come to learn, is a complication of cirrhosis, showing far gone progression of cirrhosis, w/edema, massive in the area above the stomach, almost like a pregnant woman, 10-12liters of fluid in there, weight gain first, then the body shape changing, plus hi bl press, broken veins, (spider angiomata on chest, another telltale sign of big damage), red palms, puffy appearance, plus all the other lovely affects of smoking, drinking, problems, in all areas, hating myself, giving up hope, poor me, pour me a drink.

If there's a number of drinks which cause problems, I don't know what it could be, my Dad died w/it at 35yrs old, brother had it at 38yrs old, I suppose I started cirrhosis at age 50-52, give or take, but ascites started and I couldn't get rid of that fluid..horrid, ballooned from about 185lbs to 245lbs. in six months or so, no starving helped, nothing, the fluids were staying in my body, which is wht I take meds for now. Many w/ the 'cirrhosis' w/out ascites take no meds, far as I have heard, so nutrition is everything, normal labs are a constant as I've heard too..I had them for years, now that I have had horrid labs that improved, we/Doc and I can measure.

Hope that helps? I've been in treatment w/women who say they had two to three drinks a day is all, and are sick as dogs, I find this in my experience..most exaggerate to a minimum what they actually consumed, some combined w/other drugs, some w/a hereditary pre disposition, some drinking w/food, (still counts tho they'd think it doesn't) aspirin, weight gain, all factors plus being female, smaller body parts, more damage, same drink.

Best to you to then dixie, MelanieLu

by dixiedarlin, May 02, 2003 12:00AM
To: Melanielu
I appreciate your comments.  I do understand ascites and many of the clinical manifestations of the disease.  I know everyone is different as you have said - sounds like you may have been genetically pre-disposed for the illness due to your father and brother developing it at such an early age.  Was the ascites the first sign you had of having a problem or were there others?  You mentioned 'morning after' symptoms that you ignored - what were they and were they signs of liver damage or signs of alcohol intake problems.  I hope you don't think I am being overly 'morbid' to keep asking questions but I am so interested in this topic and really want to avoid problems in the future.  I guess I 'want my cake and eat it too'.  I have had HBP for 5 years but runs in my family and it is well controlled.  I guess I am questioning things because I am getting older and in my youth - 20-30's there were a lot of 'party times' and for the past 5-10 years I have taken much better care of myself - no smoking - limited drinking and no drugs ever and good vitamin/food intake.  I will say a prayer for you......I admire your candid response and your being helpful to me......again - I will say good luck to you......DD

by MelanieLu, May 03, 2003 12:00AM
Hi again Dixiedarlin', thanks for your encouraging and supportive words. Dixie, the symptoms you ask about I'm reading are those which are/were physical? The symptoms I should've listened to were mental, the denial, often by comparison to others, thinking 'I'm not THAT bad', therefore, I couldn't be. Heck, no one wants to be what I am, an alcoholic, knowing the familial history,one would question 'nurture or nature'. It's not nurture, I wasn't raised or even knew my parents,siblings or family til much later in life. Six children were given away, the baby being under a yr old at the time my parents died. But, what I've learned at the tables and are firmly convinced of is that my disease carried with it the hallmark of alcoholics, which was denial, lasting for years on end. I've found thru MY personal experience at/around AA in and out for 20+yrs. that if we ask, we are. If we worry, we compare and come out saying 'nope, not me', til the inevitable happens. I won't call anyone else on anything.I can just/only manage me.

Symptoms, other than sick days,bad behavior,feeling run down, no sparkle in my eyes, no energy in my body to go an extra step to do more, look better or care about it,not always, sometimes.

I mentioned spider veins,red palms,HBP which was controlled by meds,but wouldn't have been there w/out the drinking,lifestyle which created 'emotional turmoil' inside ME,about so much. I was 'most attractive' in high school